OFFICE OF GENERAL COUNSEL OFFICE OF GENERAL COUNSEL PO BOX 2348 – SANTA FE, NM 87504 PHONE: (505) 827-1331 FAX: (505) 827-7729 FAIR HEARING AMENDED SUMMARY OF EVIDENCE (SOE) MEMBER IDENTIFICATION Provider: Address: Southwest Counseling Center, Inc. c/o Bryan Davis, Esq. 1005 Marquette Ave. NW Albuquerque, NM 87102 SS/TIN#: N/A DOB: N/A Hearing Case #: 17-PO-10004 Date Requested: SECTION DETAIL SECTION 1: ISSUES TO BE DECIDED On January 4, 2017 the New Mexico Human Services Department (HSD) issued a Notice of Overpayment to Southwest Counseling Center, Inc. (Southwest Counseling). Southwest Counseling submitted documents not previously provided in their SOE on May 11, 2017. HSD reviewed the documents and is seeking recoupment of Four Hundred Eighty Four and 71/100 Dollars. ($484.71). Southwest Counseling is challenging HSD’s right to recoupment SECTION 2: NARRATIVE/CHRONOLOGY OF EVENTS The Interagency Behavioral Health Purchasing Collaborative (the “Collaborative”) is authorized by statute to contract with one or more managed care organizations to develop a network of providers to address behavioral health needs in New Mexico. The Collaborative, through competitive bid process, selected OptumHealth New Mexico as the statewide entity to manage and oversee the administration of behavioral health services. Southwest Counseling, the Provider herein, had at all pertinent times, Provider Participation Agreements with Optum and HSD to provide behavioral health services to Medicaid eligible persons in New Mexico. HSD performed an independent file review of Southwest Counseling claims obtained by PCG in a random sample of 150 patient files obtained from Southwest Counseling, and determined 31 of the 150 claims failed. Southwest Counseling submitted documentation not previously reviewed that reduced the number of failed claims to 6 of 150 resulting in an overpayment of Four Hundred Eighty Four and 71/100 Dollars. ($484.71). SECTION 3: INDEX OF ATTACHED EXHIBITS A. Notice of Overpayment Demand dated January 4, 2017. B. Southwest Counseling timely request for Fair Hearing C. Extracted portion of the Public Consulting Group, Inc.’s (“PCG”) Behavioral Health Audit regarding Southwest Counseling Providing Extrapolation Foundation for Claims Universe, Seed Number and Random Claims. D. Southwest Counseling PCG Excel Spreadsheet including: Claims Universe, 150 Random Claims, Extrapolation with Seed Number; E. Provider Participation Agreements between NMHSD and Southwest Counseling; F. Southwest Counseling and United Behavioral Health, Inc. Facility Participation Agreement; G. HSD’s Claims Review Letter to Provider September, 2016; H. E-mail exchange between Mr. Davis and HSD regarding extensions of time to supplement failed claims documentation; I. HSD list and excel spreadsheet of 6 failed Random review claims with basis for failure; J. NMAC 2009; K. NMAC 2010; L. NMAC 2011; M. NMAC 2012; N. Service Code Resources; O. NMAC §8.351.2; P. NMAC §8.352.3; Q. 6 Failed Claims files; R. N/A S. N/A T. N/A U. N/A V. Prehearing Scheduling Order W. Amended Scheduling Order X. District Court Confidentiality Order Witnesses HSD submits the following list of persons who may be called to testify at the hearing in this matter. 1) Robert Stevens – Fact / Expert Witness Mr. Stevens is expected to testify regarding verification of Medicaid payment for the identified failed claims. 2) Jennifer Chavez, B.S. – Fact / Expert Witness Ms. Chavez is expected to testify regarding claims billing and recoupment of 100% of the Medicaid payment to the provider for failed claims. 3) Lisa Hahn-Cordes, J.D. – Fact Witness Ms. Hahn-Cordes is expected to testify regarding the factual basis for each identified failed claim. 4) Any witness identified by Southern New Mexico Human Development. 5) HSD reserves the right to identify and call rebuttal witnesses as deemed necessary. SOE Prepared by: John Emery, Deputy General Counsel Date: May 19, 2017 Phone: (505) 827-7701 ill MAN DEPARTMENT Susana Martinez, Governor Brent Earnest, Secretary Christopher P. Collins, General Counsel Januagy 4: 2017 VIA E-Mail and Hand Delivery Southwest Counseling Center, Inc. c/o Bryan Davis, Esq. 1005 Marquette Ave. NW Albuquerque, NM 87102 Re: Medicaid Overpayment Claim Dear Southwest Counseling Center, Inc.: Pursuant to 8.351.2.14.A and 8352.3 et seq. NMAC, please ?nd notice of overpayment based upon an independent review of the 2013 PCG random audit sample. Upon independent review of the 150 claims identi?ed by PCG, 31 were determined to have been either improperly billed or lacking in documentation. The failed claims within the sample were extrapolated to the universe of claims to determine the amount of the overpayment. Based upon this analysis HSD has identi?ed an overpayment amount of Two Million Eight Hundred Ten Thousand Four Hundred Forty One and 00/100 Dollars Attached please ?nd an excel spread sheet delineating the failed claims and the basis of the failure determination. Also attached is a copy of the extrapolation to the universe of claims resulting in the overpayment amount above. This claim is subject to amendment as the Medical Assistance Division and the Of?ce of the Inspector General are continuing to investigate the irregularities listed above, as well as additional concerns regarding potential violations of the False Claims Act, ?27-14?4 NMSA. Please be advised that actions regarding this recoupment are civil, not criminal, in nature, and do not affect or alter any potential criminal liabilities that may arise from fraudulent Medicaid practices. If you do not agree with the ?ndings, you have thirty (30) calendar days from the date of this letter to request a Fair Hearing which must be received by the HSD Fair Hearing Bureau no later than the close of business of the thirtieth day. Requests for a Fair Hearing must be in writing, dated and signed. Any request must contain a statement as to the speci?c ?ndings in dispute and the basis for your belief that the ?ndings are incorrect. In addition, when requesting a Fair Hearing, you should provide documentation that you believe supports the manner in which the services were provided and and/or billed. (See 8352.39 et seq. NMAC for details of the hearing rr?u J- ?2 Of?ce ofGeneraI Counsel Pollon Plaza, Post Of?ce Box 2348, Santa Fe, NM 87504-2348 Telephone (505) 827-770] 0 Facsimile: (505) 827-7729 Exhibit A 001 Southwest Counseling Center, Inc. January 4, 2017 Page 2 process.) You have the right to be represented by an authorized representative or legal counsel and a request for a Fair Hearing must be addressed to: New Mexico Human Services Department Fair Hearings Bureau PO. Box 2348 Santa Fe, New Mexico 87504-2348 Pursuant to 42 C.F.R. ?455.23 and 8.351.2.13.C NMAC, the pa withhold on Medicaid funds imposed on June 24, 2013 will remain in place pending resolu?bithe overpayment claim. Sincerely, Policy Bureau Human Services Department Cc: Brent Earnest, HSD Secretary Christopher Collins, HSD General Counsel Bryan Davis, Counsel for Provider Nancy Smith-Leslie, Director, Medical Assistance Division L-PJLL Ln.- Of?ce of General Counsel Pollon Plaza, Post Of?ce Box 2348, Santa Fe, NM 87504-2348 Telephone (505) 827-7701 0 Facsimile: (505) 827-7729 Exhibit A 002